Brief Allied Health Professionals Series: Direct Care Workers

Who's Who: Direct Care Workers

There are roughly 4.6 million direct care workers across America operating in a variety of settings. Direct care workers are categorized into three professions by the Bureau of Labor Statistics: certified nursing assistants, home health aides and personal care aides. Terminology for direct care workers varies greatly across states. Examples of related titles are included in the table below.

Direct care workers provide services in both institutional settings like nursing homes and assisted living facilities and home- and community-based settings like patient homes or adult day care programs.

Defining Training Requirements

States are responsible for setting training and practice requirements for direct care workers in response to local or regional needs. Varied training and certification requirements across states, however, can make it challenging to transfer across positions and settings, and limit career mobility and versatility within the direct care workforce.

Training requirements for new direct care workers vary depending on the tasks performed and setting. CNAs and home health aides are federally required to complete at least 75 hours of training. In addition to federal requirements, at least 30 states require additional CNA training and 17 states require additional home health aide training. Maine sets the highest requirements for both positions at 180 hours.

Training requirements for personal care aides are set by states, not by the federal government. At least 30 stateshave consistent requirements, such as training categories or hours required, for agency-employed personal care assistants across private and Medicaid-funded home care agencies.

Across the direct care workforce, training requirements focus on tasks associated with instrumental and other activities of daily living, such as personal hygiene, getting in and out of a wheelchair and eating. Several states have implemented additional training requirements to address patient safety and prepare workers to handle the challenges associated with direct care work. Kentucky requires at least six hours of dementia-related training within the first 60 days of employment and Colorado requires two hours of continuing education on dementia diseases and related disabilities, person-centered care, care planning, activities of daily living and dementia-related behaviors and communication.

Setting Scope of Practice

States are responsible for setting licensure requirements for health professions, but formal licensure processes vary greatly across direct care workforce positions and settings. The scope of practice for direct care workers varies greatly from state to state-in part due to the diversity of practice settings and various training models required.

CNAs may assist patients with activities of daily living and perform certain clinical tasks as delegated and supervised by another onsite licensed professional. Acceptable tasks may include basic nursing skills, infection control, basic restorative care (such as rehabilitation activities following injury) and addressing a patient's mental health and social service needs.

Home health aides are generally supervised by a registered nurse but may be supervised by another licensed provider as well. In addition to activities of daily living, home health aides may:

• Perform simple procedures as an extension of therapy or nursing services such as blood pressure reading, infection prevention and wound care.
• Assist in movement or range-of-motion exercises.
• Assist in administering medications that are ordinarily self-administered such as reminding a patient to take their medication, bringing them fluid or opening a bottle.

Personal care aides may provide activities of daily living as well as tasks such as household maintenance, chores, meal preparation and medication management. Their scope of practice does not include basic nursing or medical activities, and supervision of these tasks by a nurse or other health care provider is not usually required.

With additional training or certification, CNAs, home health aides and personal care aides may also administer medications in some states. Idaho requires unlicensed assistive professionals who are supervised by licensed nurses to complete a board-approved training program to assist patients who cannot independently administer their medication. New Hampshire authorizes certified assistant living medication aides to administer medications in certain residential settings and establishes a loan repayment program for nursing professionals. New York established a new profession, the Advanced Home Health Aide. These are home health aides who are trained to provide advanced tasks under the delegation and supervision of registered nurses, including administering routine medications. Tennessee allows a nurse to delegate authority to administer certain medications.

Establishing Career Pathways

Career pathway programs have emerged to improve the recruitment and retention of direct care workers and to better support the populations they serve.

Many states collaborate with local education institutions to establish pathway programs into and throughout the direct care workforce. New Mexico created a Spanish-language 15-week program that trains immigrants as home care workers, providing scholarships to cover the costs of tuition and childcare. Iowa established two pathway programs, one in local high schools to train students to become CNAs prior to graduation, and another with Indian Hills Community College allowing CNAs to progress to licensed practical nurse positions. Alabama established the Alabama School of Healthcare Sciences, a tuition-free, residential public high school set to open in 2026, which will provide at least 200 students with health training and certification, including direct care.

States may leverage apprenticeships and other work-based learning programs to offer youth pathways into direct care careers. Missouri and Minnesota both implemented apprenticeship programs that include opportunities for CNAs and other direct care workers to obtain additional training and work experience while continuing to receive compensation for their work.

Leveraging State and Federal Funds to Increase Wages

Despite high demand, direct care wages are often not consistent with other occupations requiring similar skills and experience. According to PHI, 1 in 4 direct care workers work part time to balance personal life demands or because full-time schedules are not available.

As the single largest payer of institutional and HCBS care, Medicaid funding has a significant impact on the direct care workforce. States can leverage Medicaid to support the direct care workforce. States can use Medicaid funds in more permanent ways to supplement payments and wages for the direct care workforce. At least 19 states are actively addressing direct care workforce wages by leveraging traditional Medicaid program funds to increase provider payment rates and wages in institutional and HCBS settings. Several states leverage wage pass-throughs, wage floor increases or wage increases tied to workforce development and training. A 2024 study by the Assistant Secretary for Planning and Evaluation examined policy changes in California, Michigan, New York, South Dakota, Tennessee and Washington. Direct care workers across states experienced several challenges, including sustainable funding sources, ensuring funds reach direct care workers and barriers to entering the field.

Outcomes-such as worker total compensation, employer financial stability and consumer service hours-are important to understand whether policy interventions are achieving their intended result. Maryland required residential service agencies, like nursing homes and assisted living facilities, to submit reports to the department of labor on personal care assistant wage rates.

As demand for long term services and supports continues to grow across the country, states are implementing a variety of strategies-including altering training requirements, redefining scope of practice and leveraging state and federal funding to strengthen the direct care workforce.